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Clinical Prevention Services Provincial STI Services 655 West 12th Avenue Vancouver, BC V5Z 4R4 Tel : 604.707.5600 Fax: 604.707.5604 www.bccdc.ca BCCDC Non-certified Practice Decision Support Tool Epididymitis EPIDIDYMITIS Testicular torsion is a surgical emergency and requires immediate consultation. It can mimic epididymitis and must be considered in all people presenting with sudden onset, severe testicular pain. Males less than 20 years are more likely to be diagnosed with testicular torsion, but it can occur at any age. Viability of the testis can be compromised as soon as 6-12 hours after the onset of sudden and severe testicular pain. SCOPE RNs must consult with or refer all suspect cases of epididymitis to a physician (MD) or nurse practitioner (NP) for clinical evaluation and a client-specific order for empiric treatment. ETIOLOGY Epididymitis is inflammation of the epididymis, with bacterial and non-bacterial causes: Bacterial: Chlamydia trachomatis (CT) Neisseria gonorrhoeae (GC) coliforms (e.g., E.coli) Non-bacterial: urologic conditions trauma (e.g., surgery) autoimmune conditions, mumps and cancer (not as common) EPIDEMIOLOGY Risk Factors STI-related: condomless insertive anal sex recent CT/GC infection or UTI BCCDC Clinical Prevention Services Reproductive Health Decision Support Tool – Non-certified Practice 1 Epididymitis 2020 BCCDC Non-certified Practice Decision Support Tool Epididymitis Other considerations: recent urinary tract instrumentation or surgery obstructive anatomic abnormalities (e.g., benign prostatic hyperplasia (BPH)) The following risk factors are more commonly seen in chronic epididymitis: trauma or strenuous physical activity sitting for prolonged periods of time (e.g., riding a bicycle or motorcycle) prior scrotal or inguinal hernia immunosuppression history of recent instrumentation, vasectomy, Beçhet’s disease, travel to areas endemic for Brucellosis or viral illness (e.g., mumps) medications that can cause epididymitis (e.g., amiodarone) CLINICAL PRESENTATION relatively quick onset of epididymal and/or testicular pain tenderness and swelling of epididymis, testis and/or scrotum (usually unilateral) symptoms of urinary tract infection (dysuria, increased frequency, urgency) symptoms of urethritis (dysuria, urethral itch, irritation or awareness, meatal erythema or urethral discharge) fever is occasionally present PHYSICAL ASSESSMENT Physical assessment specific to epididymitis may include the following: assess the epididymis, testis and scrotum for pain and swelling assess the scrotum for erythema note any urethral discharge (can ask the client to “milk” the penis) note the anatomic position of testis palpate inguinal area for hernias assess for Fournier’s gangrene (necrotizing fasciitis of the perineum; can see acute scrotal swelling, severe pain in anterior abdominal wall spreading to gluteal muscles, scrotum and penis) assess temperature BCCDC Clinical Prevention Services Reproductive Health Decision Support Tool – Non-certified Practice 2 Epididymitis 2020 BCCDC Non-certified Practice Decision Support Tool Epididymitis Practitioner Alert! Testicular torsion is a surgical emergency and requires immediate consultation. DIAGNOSTIC AND SCREENING TESTS If urethral discharge is present, collect swab(s) for: GC culture and sensitivity (C&S) CT/GC NAAT swab If urethral discharge is not present, collect a urine specimen for CT/GC NAAT. If enteric infection(s) or genitourinary bacteriuria suspected: collect urine specimen for dipstick o order urine culture if: . dipstick positive for leukocytes, nitrites and/or blood . dipstick negative, but symptomatic with urethral symptoms A MD or NP may order an ultrasound (U/S) or do a digital rectal examination to help clarify a diagnosis. Arranging to get an U/S should not delay an urgent surgical consult if testicular torsion is suspected. MANAGEMENT Diagnosis and Clinical Evaluation RNs must consult or refer all suspect cases of epididymitis to a MD or NP for clinical evaluation and a client-specific order for empiric treatment. BCCDC Clinical Prevention Services Reproductive Health Decision Support Tool – Non-certified Practice 3 Epididymitis 2020 BCCDC Non-certified Practice Decision Support Tool Epididymitis Consultation and Referral All suspect cases of epididymitis must be referred to a MD or NP for evaluation and a client- specific order for empiric treatment. BCCDC Clinical Prevention Services Reproductive Health Decision Support Tool – Non-certified Practice 4 Epididymitis 2020 BCCDC Non-certified Practice Decision Support Tool Epididymitis Treatment Recommended treatment options for gonorrhea reflect both current local antimicrobial resistance trends (see BCCDC Laboratory Trends Newsletters) and national STI guidelines. RNs must consult or refer all suspect cases of epididymitis to a MD or NP for clinical evaluation and a client-specific order for empiric treatment. Treatment Notes If condomless insertive anal sex, treat 1. Treatment for epididymitis CT/GC infections. for enteric pathogens and provide CT/GC coverage 2. Review information on the BCCDC Medication Handouts and your agency’s drug reference database, cefixime 800 mg PO in a single dose including: AND Allergies, interactions and side effects fluoroquinolone (e.g., levofloxacin) How to take the medication After-care information ceftriaxone 250 mg IM in a single dose 3. Cefixime AND DO NOT USE if allergy to cephalosporins. fluoroquinolone (e.g., levofloxacin) Consult with or refer to MD or NP if history of anaphylaxis or immediate reaction to penicillins. If < 35 years and no condomless insertive anal sex, treat for CT/GC 4. Ceftriaxone infection DO NOT USE if allergy to cephalosporins. cefixime 800 mg PO in a single dose To minimize discomfort, use 0.9ml lidocaine 1% (without epinephrine) as the diluent for ceftriaxone IM. AND Ventrogluteal site is preferred. doxycycline 100 mg PO BID for 10 days Review potential for side effects: pain, redness and swelling at the injection site, or diarrhea. If these persist ceftriaxone 250 mg IM in a single dose or worsen, advise to contact a health care provider. AND 5. Lidocaine doxycycline 100 mg PO BID for 10 days DO NOT USE if allergy to local anaesthetics. If ≥ 35 years and no condomless 6. Doxycycline insertive anal sex, cover enteric pathogens DO NOT USE if allergy to doxycycline or other tetracyclines. fluoroquinolone (e.g., levofloxacin) Take with food/water to avoid potential adverse gastrointestinal effects. RE-TREAT if 2 consecutive doses are missed within the first 5 days of treatment, or if 5 days of treatment is not completed. 7. Fluroquinolones: provide CT coverage (e.g., levofloxacin). MD/NPs can check local antibiograms (e.g., BCCDC, Lifelabs). BCCDC Clinical Prevention Services Reproductive Health Decision Support Tool – Non-certified Practice 5 Epididymitis 2020 BCCDC Non-certified Practice Decision Support Tool Epididymitis Monitoring and Follow-up Repeat testing: No Test-of-cure (TOC): No Follow-up: if test results are positive for CT/GC, review MD/NP treatment and follow- up plan, and confirm client received adequate treatment for the infection(s) Partner Counselling and Referral Reportable: No If CT/GC infection is confirmed, refer to the appropriate DST for partner counselling and referral information. Trace-back period: last 60 days. If no partners during this time, last sexual contact Recommended partner follow-up: if CT/GC is the confirmed or suspected cause, empirically test and treat all contacts (see the Treatment of STI Contacts DST) Potential Complications chronic epididymitis infertility testicular abscess testicular infarction Additional Client Education Counsel client: that pain and erythema should resolve within 3 to 7 days. that it could take a few weeks after the completion of antibiotics for symptoms to completely resolve, although should see improvement during first week of therapy. to complete all treatment as directed even if symptoms improve or resolve. to avoid sexual contact until the client and their partner(s) have completed screening and treatment, and symptoms have resolved. to use of analgesics (e.g., NSAIDs), rest and scrotal elevation to help alleviate pain Standard Client Education for Sexually Transmitted Infections and Blood-Borne Infections (STBBI) BCCDC Clinical Prevention Services Reproductive Health Decision Support Tool – Non-certified Practice 6 Epididymitis 2020 BCCDC Non-certified Practice Decision Support Tool Epididymitis REFERENCES Al-Kandari AM, Kehinde EO, Khudair S, Ibrahim H, ElSheemy MS, Shokeir AA. Intermittent Testicular Torsion in Adults: An Overlooked Clinical Condition. Medical principles and practice : international journal of the Kuwait University, Health Science Centre. 2017;26(1):30–4. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5588398/. Australasian Sexual Health Alliance (ASHA). Australian STI management guidelines for use in primary care. Epididymo-orchitis. 2018. Available from: http://sti.guidelines.org.au/syndromes/epididymo-orchitis. Bradford R, Farry S, Kyle JA. Antibiotic Therapy for Epididymitis. U.S. Pharm. 2015:40(8):39- 43. Available from: https://www.uspharmacist.com/article/antibiotic-therapy-for- epididymitis. British Columbia Centre for Disease Control (BCCDC). British Columbia Treatment Guidelines. Sexually Transmitted Infections in Adolescent and Adults. STI/HIV Prevention and Control Division, BC Centre for Disease Control. 2014. Capet J, Sønsksen J, Bisbjerg R,
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